Vegetable Gardening and Health Outcomes in Older Cancer Survivors

This randomized clinical trial investigates whether vegetable gardening improves vegetable and fruit consumption, physical activity, and physical function outcomes among Medicare-eligible cancer survivors.


Introduction
The benefits of gardening were first reported by Cicero in 46 BC. 1 More recently, a meta-analysis of 1046 older adults from 13 randomized clinical trials (RCTs) and 2 cohort studies found that gardening was associated with improved physical functioning, increased physical activity, reduced body mass index (BMI), and improved quality of life. 2 A systematic review also found that access to one's own vegetable garden was an environmental factor associated with vegetable and fruit intake. 3[6] Over a decade ago, the Harvest for Health feasibility trial was conducted among 12 survivors of breast, prostate, and childhood cancers residing in Jefferson County, Alabama. 7 It was a partnered effort between an academic medical center (which recruited and enrolled participants and assessed changes in diet, physical activity, and physical functioning) and the Auburn University Horticulture Extension Office cooperative extension (which deployed extension-certified master gardeners [EMGs] to provide biweekly mentorship on planning, planting, and caring for a spring, summer, and fall raised-bed garden at participants' homes).The trial demonstrated full accrual within a week, 83.3% retention over 1 year, and safety. 7Preintervention and postintervention assessments suggested improvements in physical performance, 8 increased vegetable and fruit intake, and increased moderate-to-vigorous physical activity (MVPA). 7The study was expanded to 82 breast cancer survivors residing in metropolitan Birmingham, Alabama, and then statewide to 46 older survivors of various cancers using a 2-arm RCT design with comparison against a waitlist control. 9th trials evaluated the Harvest for Health intervention, which was modified to supply either raised beds or 4 grow boxes of comparable square footage to increase reach to survivors who resided in condominiums or rental properties.Findings of both trials demonstrated feasibility (ie, 82%-100% accrual, 91%-95% retention, absence of serious attributable adverse events, and 100% "good-toexcellent" satisfaction).The trial among breast cancer survivors found significantly greater improvements in the intervention vs waitlisted arms in MVPA (114 vs −17 minutes per week), 2-minute step test (122 vs 110 steps), and arm curl test (12.7 vs 10.1 repetitions), 10 whereas the RCT among older survivors found significantly attenuated increases in waist circumference (2.30 cm vs 7.96 cm). 11Both feasibility studies found trends toward higher vegetable and fruit intake.These positive findings, plus those from survey studies, 12,13 observational studies, 14 and gardening interventions in other populations, 2,[15][16][17][18][19][20][21]

Methods
Harvest for Health was a 2-arm, single-blinded RCT that used a waitlist-controlled, crossover design to test the effects of a home-based gardening intervention on vegetable and fruit intake, physical activity, physical functioning, quality of life, sleep, adiposity, gut microbiome, and inflammatory biomarkers.Individuals assessing outcomes and conducting analyses were blinded to arm assignment.This study was approved by the University of Alabama at Birmingham (UAB) institutional review board (NCT02985411; the trial protocol is given in Supplement 1).All study participants provided written informed consent.We followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline.The study period spanned May 11, 2016, to May 2, 2022, with detailed methods and recruitment results published previously. 22

Participants
Medicare-eligible cancer survivors who were diagnosed with and had completed curative therapy for cancers with 5-year survival of 60% or more 22 were ascertained through UAB or Alabama state cancer registries and approached via direct mail 23 followed by telephone contact.Referrals responding to media also were enrolled after verification of diagnoses by health care practitioners.
Interested survivors were screened for suboptimal vegetable and fruit consumption (<5 servings per day), physical activity (<150 MVPA minutes per week), physical functioning (36-Item Short Form Health Survey [SF-36] subscale score Յ90 [score range, 0-100, with higher scores indicating better physical functioning]), and living independently at a residence that could accommodate 1 raised bed (1.2 × 2.4 m) or 4 grow boxes (62.2 × 52.1 cm) with 6 or more hours per day of sunshine and ready access to water.Other criteria were ability to speak, read, and write English and willingness to participate for 2 years with randomization to either study arm.Exclusion criteria included vegetable gardening within the past 2 years or medical conditions that precluded gardening.All study participants were followed up from initial contact until study completion or termination according to the CONSORT guideline. 24

Assessments
Assessments occurred at baseline (before randomization) and 12 months and included anthropometric measures (height [baseline only], weight, and waist circumference), 25 physical performance testing (Senior Fitness Battery 8 ), accelerometry (7-day collection via GTPX3 accelerometer [ActiGraph]), the Community Healthy Activities Model Program for Seniors (CHAMPS) Physical Activity Questionnaire for Older Adults, 26 blood collection via venipuncture (after Ն4 hours of fasting), and collection of toenail clippings and a fecal wipe.Plasma and serum samples and fecal wipes were stored at −80 °C and toenails at room temperature 27 and then batch-analyzed following published methods for α-carotene, 28 cortisol, 29 fecal microbiome, [30][31][32][33] and inflammatory biomarkers. 22A remote protocol was implemented in April 2020 due to the COVID-19 pandemic.It omitted grip strength, arm curl, and gait speed measures from the performance battery because of cost or failure to prove reliability, 22,34 and dried blood spots (found valid and reliable for interleukin-6 [IL-6]) and tumor necrosis factor-α [TNF-α]) supplanted venipuncture.Assessment of plasma α-carotene levels (an objective measure of vegetable and fruit intake) was not possible.Surveys administered online (REDCap) or by mail captured self-reported race, ethnicity, comorbidities, and symptoms 35 ; falls 36 ; perceived stress 37 ; reassurance of worth 38 ; sleep quality 39 ; vegetable and fruit consumption 40 ; physical activity 26 ; quality of life 41 ; and changes in health.Race and ethnicity were included in the analysis as potential effect modifiers; categories were African American or Black, non-Hispanic White, and other (included American Indian, Asian, Pacific Islander, Hispanic, and multiracial; combined into 1 category because <2% of participants identified as a race other than African American or Black or White and/or as Hispanic ethnicity).

Randomization and Intervention
After conclusion of the baseline assessment, a staff member opened a sealed envelope (created by a statistician) to reveal the randomization assignment.Participants were evenly allocated within each county to receive the intervention immediately or to be waitlisted using computer-generated permuted block randomization.In the intervention group, the EMGs were paired with cancer survivors within counties of residence and visited survivors' homes monthly to help establish and then maintain a spring, summer, and fall garden.Telephone, email, or text messages were scheduled between visits, with social cognitive theory undergirding all communications. 42The EMGs logged all encounters and provided time-stamped garden photographs.Each participant received a 1.2 × 2.4-m raised bed kit (or 4 grow boxes), soil, fertilizer, mulch, frost cloths, tomato cages, trellises, gardening hose, watering can, trowel, cultivator, soft chemistry insect control products, seeds, transplants, and a gardening journal.Participants and EMGs received hats, sunscreen, and binders with contact information, interaction tracking logs, and publications on gardening, safety, health, and vegetables and fruits (including recipes).Supplies were distributed at EMG-participant meet-and-greets (informational sessions and social events) at local community centers before initial planting.During the COVID-19 pandemic, meetings were conducted via videoconferencing and supplies were distributed in parking lots; all EMG-participant interactions were restricted to masked, outdoor encounters.Waitlisted participants received the identical intervention after 12 months.

Statistical Analysis
A composite dichotomous score (yes or no) served as the primary outcome based on baseline-to-12month attainment of the following benchmarks: increased consumption of 1 or more vegetable and fruit servings per day, corroborated by an increase of at least 10% in plasma α-carotene level 43 ; 30 or more minutes of MVPA per week, corroborated by accelerometry; and increase of at least 5 SF-36 physical functioning subscale points, corroborated by improved scores in at least 60% of physical performance tests.Power calculations indicated that 185 participants per arm would yield more than 90% power to detect between-arm differences using χ 2 testing (assumptions: 15% attrition and a moderate response difference Ն20%). 44scriptive statistics and normality checks were performed on continuous variables (results from transformed analyses were similar).All statistical tests were 2-sided (α < .05)and conducted using SAS, version 9.4 (SAS Institute Inc); an intent-to-treat approach was used for all analyses.
Continuous outcomes were explored using linear mixed-effects models, including fixed effects for group, time, and group × time interaction, with a random intercept for participants estimated using restricted maximum likelihood.The mean change at 12 months vs baseline within each group and the difference in mean change between groups, with corresponding 95% CIs, were reported.
Categorical secondary outcomes (weight, waist circumference, health-related quality of life, reassurance of worth [Revised Social Provision Scale], self-efficacy to garden, social support to garden, sleep quality, perceived stress, cortisol level, IL-6 level, TNF-α level, and microbiome alpha diversity) were explored using logistic mixed-effects models with the same aforementioned model terms and assumed a binary or multinomial response distribution.Odds ratios (ORs) and their corresponding 95% CIs were reported.
Linear mixed-effects models are robust against missing data, as they can accommodate unbalanced data patterns 45,46 ; thus, all available observations and participants were included in the analysis.For each outcome, participants with at least 1 nonmissing outcome measure were included in the analysis.
Logistic regression analyses were performed to determine whether garden type (raised beds or grow boxes) and EMG contact of 90% or more vs less than 90% modified the effects.Other

Results
This trial randomized 381 survivors of a variety of cancers with dates of diagnosis preexisting enrollment by 2 to 43 years and ages spanning 50 to 95 years (mean [SD] age, 69.8 [6.4]

years) to
Harvest for Health (194 participants) or the waitlist control (187 participants) (Table 1).A total of 263 participants (69.0%) were female, and 118 (31.0%) were male; 67 (17.6%) were African American or Black; 296 (77.7%), non-Hispanic White; 7 (1.8%),other race and ethnicity; and 11 (2.9%), unknown race and ethnicity.Most were married, urban dwelling, and currently retired or unemployed.A total of 218 (57.2%) were college graduates, and 94 (24.7%) reported an annual income less than $30 000.While few survivors were current smokers, 310 (81.4%) had a BMI of 25 or greater, and participants ate a mean (SD) of 2.1 (1.7) servings of fruits and vegetables a day, less than half of the recommended amount. 47While participants were screened with 1 item to verify suboptimal physical activity, results of accelerometry and the longer CHAMPS Physical Activity Questionnaire at the baseline assessment revealed higher physical activity levels. 26tails on enrollment and postrandomization events are shown in Figure 1.Among the older cancer survivors participating in this trial during the COVID-19 pandemic, 14 (7.2%) in the intervention arm and 13 (7.0%) in the waitlisted arm were excluded before receiving their full assigned study condition.These postrandomization exclusions were evenly distributed between arms, with approximately one-quarter of these participants being excluded due to cancer progression (intervention, 6 [3.1%]; control, 3 [1.1%]),another quarter due to death (intervention, 5 [2.6%]; control, 2 [1.1%]), and another quarter due to subsequently divulging that they were gardening at baseline (intervention, 1 [0.5%]; control, 6 [3.2%]).Two participants (1.1%) assigned to the waitlist refused their randomization assignment.Three participants in each arm (intervention, 1.5%; control, 1.6%) withdrew or were lost to follow-up; thus, the intent-to-treat analysis included a sample of 180 in the intervention arm and 174 who were waitlisted.No between-arm differences in dropouts or adverse events were detected (the only attributable adverse event was nonserious minor bruising from a fall occurring while harvesting vegetables).
Figure 2 depicts percentages of survivors in each arm who demonstrated benchmark improvements in primary outcomes; the intent-to-treat analysis did not detect a significant improvement in the composite index of vegetable and fruit intake, physical activity, and physical function (intervention arm vs waitlisted arm, 4.5% vs 3.1%; P = .53).With the exception of selfreported MVPA, greater baseline-to-12-month improvements were observed in the intervention arm compared with the waitlisted arm.These data showed consistent directionality, although no significant between-arm differences were detected.Table 2 provides continuous data on each of these variables.There were several significant within-and between-group differences.For example, a significant improvement in daily servings of vegetables and fruits was detected in the intervention arm (mean change, 0.3 servings; 95% CI, 0.0-0.6 servings; P = .04),whereas no difference was observed among controls (mean change, 0.0 servings; 95% CI, −0.3 to 0.2 servings; P = .76);plasma α-carotene levels paralleled these values.While no significant between-arm differences were detected in vegetable and fruit consumption (mean difference, 0.3 servings per day; 95% CI, −0.1 to 0.7 servings per day; P = .10),between-arm differences were found for both the 2-minute step test ).The only variable that significantly moderated effects within the entire sample was the COVID-19 pandemic, for which significantly greater odds of improvements in self-reported physical functioning (difference of 5 points) were observed among participants who completed the study before vs during the pandemic (OR, 2.17; 95% CI, 1.12-4.22;P = .02).
Table 3 provides secondary outcome data.A modest weight loss of 0.8 kg over 12 months was observed with the gardening intervention but not among controls (mean between-arm difference, −1.0 kg; 95% CI, −2.2 to 0.1 kg; P = .08).Significant between-arm differences were noted for perceived health, which improved in the intervention arm but not among controls (8.4 points [95% CI, 3.0-13.9points] on a 100-point scale, with higher scores indicating better health; P = .003).Other quality-of-life outcomes (eg, physical and emotional role and general health) improved in both arms, with no between-arm differences.Inflammatory markers (cortisol, IL-6, and TNF-α) remained fairly stable over the study period in both groups.Likewise, no significant between-arm differences were found for gardening self-efficacy (a hypothesized intervention mediator); however, significant potential effect modifiers (cancer type [breast and gynecologic cancer vs others], time elapsed from diagnosis [<5 years vs Ն5 years], age [<70 years vs Ն70 years], sex, race and ethnicity [non-Hispanic White as the reference group], educational attainment [high school graduate or less vs above], household size [1 vs Ն2 members], annual income [<$60 000 vs Ն$60 000], rural or urban county of residence, BMI [<30 vs Ն30; calculated as weight in kilograms divided by height in meters squared], vitality [<70% vs Ն70% of the SF-36 subscale score], 41 garden start season [spring vs others], and trial completion before vs during the COVID-19 pandemic) were explored similarly.

Figure 2 .
Figure 2. Percentages of Survivors in Each Arm Who Demonstrated Benchmark Improvements in Primary Outcomes Abbreviations: IL-6, interleukin 6; PSQI, Pittsburgh Sleep Quality Index; QOL, quality of life; SPS, Revised Social Provision Scale; TNF-α, tumor necrosis factor α. a Established from linear mixed-effects models.
reinforce that adequately powered trials to formally test the benefits of gardening interventions among cancer survivors are needed.Herein, we report the results of the fully powered Harvest for Health RCT that was tested among Medicareeligible cancer survivors across Alabama.

Table 1 .
Characteristics of the Harvest for Health Study Sample

Table 1 .
Characteristics of the Harvest for Health Study Sample (continued)Abbreviation: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared).Restricted to participants with 5-year survival rates of 60% or greater (in situ or localized cancers of the bladder or cervix, gastric cardia, or early-stage multiple myeloma; in situ or locoregionally staged melanoma and cancers of the colorectum, endometrium, kidney or renal pelvis, oral cavity or pharynx, ovary, prostate, thyroid, or female breast; and all stages of testes cancer, leukemia, and Hodgkin or non-Hodgkin lymphoma).Normal was defined as 18.5 to less than 25.0, overweight as 25.0 to less than 30.0, and obese as greater than or equal to 30.0.(significant decline in waitlisted arm: −5.4 steps [95% CI, −9.1 to −1.7 steps]; mean between-group difference, 6.0 steps [95% CI, 0.8-11.2steps]; P = .03)and the 30-second chair-stand test (significant improvement in intervention arm: 0.6 repetitions [95% CI, 0.2-1.1 repetitions]; mean betweengroup difference, 0.8 repetitions [95% CI, 0.1-1.5 repetitions]; P = .02).These results were consistent regardless of EMG contact.However, there was evidence of significant effect moderation.In analyses of the intervention arm alone, participants who were more proximal to diagnosis demonstrated a b Lymphoma, thyroid, head and neck, melanoma, or multiple myeloma.cIncludedAmerican Indian, Asian, Pacific Islander, Hispanic, or multiracial.These were combined into 1 category because less than 2% of participants identified as a race other than African American or Black or White and/or as Hispanic ethnicity.dAccording to the 36-Item Short Form Health Survey physical function subscale.e

Table 2 .
Primary Outcome Variables in the Harvest for Health Trial in Older Cancer SurvivorsOnly assessed among participants who completed the trial prior to the onset of the COVID-19 pandemic (95 in the intervention arm and 80 in the waitlisted arm).
a Established from linear mixed-effects models.bBasedon the Eating at America's Table Study.cdBased on the Community Healthy Activities Model Program for Seniors Physical Activity Questionnaire for Older Adults.eScoresrange from 0 to 100, with higher scores indicating better functioning.

Table 3 .
Secondary Outcomes in the Harvest for Health Trial in Older Cancer Survivors

Table 2 .
37sed on the Perceived Stress Scale.37Sleep;Ashley Smith; Fariha Tariq, MPH; Amelia Warnock, MPH; Bria Wilson, MPH; Alec Daylon Wingate; and Elli Zorn, students at UAB, provided help with recruitment and data collection.The following individuals were paid consultants: Jennifer De Los Santos, MD, Grandview Medical Center, provided input on recruitment, and Mark Conaway, PhD, University of Virginia; Patricia Ganz, MD, University of California, Los Angeles; Madeline Harris, RN, MSN, OCN, Women's Breast Health Fund; and Amy Clayton, a patient advocate, were external data safety and monitoring board members.Meredith Kilgore, MD, UAB, who died October 17, 2018, contributed to securing funding and received salary support.
c On a 100-point scale, with higher scores indicating better health.dOdds ratio (95% CI).e